Buprenorphine Inpatient

Patient meets criteria for severe opiate use disorder by DSM 5 criteria. Risks/benefits/alternatives were discussed in detail and patient has made an informed decision to begin buprenorphine.

·       Check HIV/HCV/HBV/LFTs/Utox/Preg test if not done

·       If pregnant, obtain FHTs or NST as indicated

·       Request an ADTS consult. Educated on harm reduction.

·       Educate patient and RN that buprenorphine is a sublingual formulation and proper technique.

·       Ensure patient has had NO opiates for at least 6 hours (short acting). Note, long acting opiates and methadone may take up to 36 hours for the initiation of withdrawal.

·       Day 1: Check COWS when in withdrawal:

o   if <8, reassess every 2 hours while awake until COWS >8

o   Once >/= 8

§  administer 4mg of buprenorphine/naloxone and reassess COWS in 1.5 hours.

·       COWS <8: reassess in 6 hours as needed

·       COWS >/=8, dose again and then reassess every 6 hours as needed

o   Can repeat COWS and dosing every 6 hours as needed

o   Max dose day 1= 16mg total (average 8-12 mg)

·       Day 2: Give total Day 1 dose on Day 2 as a once daily dose in the AM.

o   May add an additional 2-4 mg as needed throughout the day

o   Max dose day 2= 20mg total

·       Day 3+: Give total Day 2 dose on Day 3 as a once daily dose in the AM unless divided dosing needed for pain/anxiety.

o   Max dose 24mg


Tips:

-       May divide dosing as needed for pain/anxiety. May decrease dose as needed for any adverse effects.

-       By 72 hours, ensure an x-waiver provider is involved in this case. Prior to 72 hours, any provider may begin buprenorphine.



** Caution: Expert consultation for any of the below:
- In pregnancy, use buprenorphine mono-product
- If methadone used in past week

- LFTs >5x ULN

- Surgery/Procedure in next 48 hours

- Severe acute pain (mild-mod pain can consider splitting dose to BID-q6) or adding a full agonist PRN (hydromorphone or fentanyl)

- recent use of other sedatives (benzodiazepines, barbiturates, z-drugs, opiates, EtOH)


The following adjunctive medications can be used for symptom control:
- acetaminophen 650mg q6 prn pain (as tolerated by LFTs).
- clonidine 0.1-0.3 mg PO q6-8 hours prn vasomotor symptoms (hold if BP< 100/70 and NTE 1.2 mg/day).
- hydroxyzine 25mg po q6 hours prn anxiety.
- trazadone 50-100mg po qhs prn insomnia.
- loperamide 4mg po initially, then 2 mg PRN each additional loose stool (NTE 16mg/24 hours).

- ondansetron 4mg po/SL/IV q6 hours prn nausea.

- melatonin 3mg po qhs prn insomnia.

 

On Discharge:

- Please provide enough Rx for patient to last until an appointment with a bup provider. Rx must come from a x-waivered provider. Appointment with bup provider should be within 1 week and max Rx given should be a 7 day supply.    

- Provide discharge rx for nasal naloxone.

- Consider PEP for HIV if indicated.

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